DEMOGRAPHIC INFORMATION What is your race/ethnicity? ... Masters. PhD. Vocational or. Trade School. PROFESSIONAL LICENSU
UNIVERSITY CITY DISTRICT
West Philadelphia Skills Initiative Training Program Application APPLICANT INFORMATION
Today’s Date
Job Title Applying for: Full Name:
Apt./ Unit # 19131
Street Address: You must reside in one of the following ZIP codes. Choose One: Phone: ( Date of Birth: MM / DD / YYYY
Marital Status:
)
19104
19139
19143
19151
E-mail Address: /
Social Security No.:
/
Single
- # # -####
xxx-xx-xxxx
Married
Have you ever been convicted of a crime?
Widowed YES
Separated
Divorced
NO
(A criminal background does not exclude you from participation in this program.) Are you legally eligible to be employed in the United States? Are you presently employed?
YES
DEMOGRAPHIC INFORMATION
NO
YES
Gender:
NO
Male
Domestic Partner
If YES, convicted of: Misdemeanor(s)
Female
Other
Common Law
Felony(s)
How did you hear about us?
If YES, you are not eligible for this program.
What is your race/ethnicity? Check all that apply.
American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Pacific Islander
White
Hispanic or Latino
Other ____________________
EDUCATION Name of School
Course of Study
Years Completed
Date Completed MM / DD / YYYY
Highest Degree Received GED Diploma Associates Bachelors Masters PhD
High School College Graduate Work Vocational or Trade School
PROFESSIONAL LICENSURE/CERTIFICATION Name of School
Type of License
License Number
Expiration Date MM / DD / YYYY
Application Continues on Next Page
© University City District 2016
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Updated 1/2016
EMPLOYMENT HISTORY
Please tell us about your employment history, starting with your most recent position.
Company:
Phone: (
Full Address:
Supervisor’s Name and Title:
Hire Date:
Exit Date:
(MM / DD / YYYY)
(MM / DD / YYYY)
Reason for leaving?
)
Resigned Retired
Terminated Temporary
Laid-off Other
Please explain why you left: Job Title:
Hourly Wage: $________per hour
# of Hours Worked per Week:
Describe the work you performed: Company:
Phone: (
Full Address:
Supervisor’s Name and Title:
Hire Date:
Exit Date:
(MM / DD / YYYY)
(MM / DD / YYYY)
Reason for leaving?
)
Resigned Retired
Terminated Temporary
Laid-off Other
Please explain why you left: Job Title:
Hourly Wage: $________per hour
# of Hours Worked per Week:
Describe the work you performed:
ADDITIONAL QUALIFICATIONS What skills, experience, or training do you have that will make you a great candidate for this program?
STATEMENT OF INTENT Why do you want to be a part of the West Philadelphia Skills Initiative? Applications without a statement of intent will be rejected.
DISCLAIMER AND SIGNATURE I certify that my answers are true and complete to the best of my knowledge. If this application leads to entry into the program, I understand that false or misleading information in my application or interview may result in my release. Signature:
Date:
Thank you for applying to University City District’s West Philadelphia Skills Initiative. Please submit your completed application with your resume: By Mail
West Philadelphia Skills Initiative 3940 Chestnut Street Philadelphia, PA 19104
By Fax
215-243-0557
By Email
[email protected]
Incomplete applications will not be accepted.
Applications submitted with resumes will receive priority consideration. © University City District 2016
Page 2 of 2
Updated 1/2016
